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AMERITA
DSH450801 CHRISTUS ST MICHAEL
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Covered Entity Details
Entity Name
CHRISTUS ST MICHAEL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450801
Entity Address
2600 ST MICHAEL DRIVE
TEXARKANA, TX 75503
Medicare Provider Number
450801
Participating Start Date
4/1/2015
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
AMERITA
Pharmacy Address
CENTRAL LINE INFUSION DALLAS
8080 TRISTAR DR STE 120
IRVING, TX 75063-2823
Pharmacy Comments
Contract Details
Approval Date
7/9/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jason Rounds, Interim President and CEO
(903) 614-2003
Contract Pharmacy Representative
Amerita, Inc.
Dan Van Valkenburg, Director, 340B Program
(810) 434-2710
Signed By Date
7/9/2019
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